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WMR0010.1177/0734242X18755894Waste Management & ResearchIshtiaq et al.

Original Article

Waste Management & Research

A multi-criteria decision-making
2018, Vol. 36(4) 386­–394
© The Author(s) 2018
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DOI: 10.1177/0734242X18755894
https://doi.org/10.1177/0734242X18755894

selection criteria for hospital journals.sagepub.com/home/wmr

waste management: A case from

Pakistan

Palvisha Ishtiaq1, Sharfuddin Ahmed Khan2

and Moiz-ul Haq3

Abstract
To address environmental issues and cost effectiveness, waste management is necessary for healthcare facilities. Most importantly,
segregation of hazardous and non-hazardous waste must be done as in many developing countries; disposal of both types of healthcare
waste is done together, which is an unsafe practice. Waste generated in hospitals needs proper management to minimise hazards
for patient and healthcare workers. At the same time, it is quite difficult for hospitals to find a systematic way to select appropriate
suppliers for hospital waste management. Therefore, the purpose of this article is to identify, validate, and rank criteria that are
essential for hospital waste management suppliers’ selection. The analytical hierarchal process approach has been used and a survey
from Pakistan’s largest city (Karachi) has been considered to rank the most appropriate criteria that is necessary to select the supplier,
especially in a developing country like Pakistan. Results show that waste management cost (45.5%) and suppliers’ details (31.5%)
are the top two main criteria for supplier selection; and storage cost (15.7%), waste handling cost (14.7%), and qualification of the
suppliers (10.9%) are the top three most important overall sub-criteria for supplier selection for hospital waste management.

Keywords
Waste, hospital waste, waste management, supplier selection, supplier selection criteria, analytical hierarchal process

Received 31st July 2017, accepted 21st December 2017 by Editor-in-chief P Agamuthu

Introduction
Any undesired or bootless material that is deliberately disposed of
by its consumers is termed ‘waste’. The capability to deal with
such materials in an expeditious way to vanish their adverse
effects is termed ‘waste management’. Expanding standards of
life and enlarging world population is putting a whirlwind increase
in waste generation. As per United Nations Environment
Programme (UNEP) research of 2005, waste generation in devel-
oped countries is almost six times more than in developing coun-
tries; despite the growing rate of population, waste generation is
increasing swiftly in developing countries (Okalebo et al., 2014).
Muduli and Barve (2012) conducted research on challenges faced
during biomedical waste management in India. Most significant
challenges noted were: Lack of waste segregation, lack of correct
operational strategies, lack of green purchase policy, disengage-
ment from the top management, lack of staff training, lack of
institutional arrangements and inadequate facilities along with
poor regulatory measures, inability to reuse waste material, finan-
cial constraints, and others. Similarly, a qualitative research article
was written by Asima et al. (2015) on challenges in healthcare
solid waste management. Khatib et al., (2009) assessed healthcare
waste management and specified healthcare waste material gener-
ated in the hospitals. Similarly, Arab et al. (2008) and Farzadkia et
al. (2009) evaluated hospital waste management, including segre-
gation, containment, elimination, and disposal of waste materials
in public hospitals. Ahmed and Ahmed, (2008) performed a thesis
work to examine the current biomedical waste management
1Supply Chain Department, Aspin Pharma (Pvt) Ltd, Karachi, Pakistan
2IndustrialEngineering and Engineering Management Department,
University of Sharjah, Sharjah, United Arab Emirates
3Engineering Department, Prime Engineering Methods (Engineers &
Contractors), Karachi, Pakistan
Corresponding author:
Sharfuddin Ahmed Khan, Industrial Engineering and Engineering
Management Department, University of Sharjah, Sharjah, United
Arab Emirates.
Email: skhan@sharjah.ac.ae
Ishtiaq et al. 387
practices in Karachi and compared it with the past practices.
Healthcare waste management practice in 2000s era is noticed to
be improved as compare to late 1990s, but still it is inappropriate
and dangerous. The key reason behind this is improper waste
management strategies and systems of regular hospitals. In addi-
tion, the highlighted issues that are acting as a hurdle in healthcare
waste management are non-implemented regulatory laws and
regulations, unavailability of funds to manage biomedical waste
at government hospitals, poor monitoring system, untrained staff,
etc. Epidemiological awareness and practises are at central stage
in Pakistan (Ahmed and Ahmed, 2008). A detailed report was pre-
sented by JSI-PAIMAN report (2006) on the John Snow Inc. (JSI)
and Pakistan Initiative for Mothers and New-borns (PAIMAN)
project, in contribution with the United States Aid, having a topic
of hospitals waste management and environmental assessment
within overall Pakistan. Different facilities are selected in
Rawalpindi, Dera Ghazi Khan, Khanewal, Jhelum, etc. Improper
waste handling, collection, segregation, transportation, and dis-
posal are observed.
Supplier selection is a strategic decision and during the sup-
plier selection process, we need to select suppliers based on
different criteria, which are mostly conflicting in nature. Many
authors applied different multi-criteria decision-making
(MCDM) methods in supplier selection, such as fuzzy systems,
technique for order of preference by similarity to ideal solution
(TOPSIS), data envelop analysis (DEA), analytical hierarchal
process (AHP), analytical network process (ANP), etc. The
AHP technique is a widely used MCDM technique, usually in
contradictory situations, and many researchers successfully
implemented AHP in many areas, such as the automotive indus-
try (Dweiri et al., 2016), washing machine industry (Patel et al.,
2013), gear motor manufacturing industry (Ayhan, 2013), TV
manufacturing (Singh, 2012), steel manufacturing (Tahriri et
al., 2008), tractor manufacturing industry (Shahraki et al.,
2011), hotel industry (Sakhuja et al., 2015), vehicle tyre manu-
facturing (Soroor et al., 2012), warehouse performance evalua-
tion (Khan et al., 2016), contractor selection (Khan and
Al-Hosany, 2016), and forecasting methods selection (Dweiri et
al., 2015). Similarly, many authors used AHP in waste manage-
ment, bio medical waste management, medical hazardous waste
disposal, and reverse logistics service provider selection (see
Agarski et al., 2011; Buyukozkan and Gocer, 2011; Jain and
Khan, 2017; Khan et al., 2016; Taghipour et al., 2014; Tot et al.,
2016; Ghanavati et al., 2016).
The development of an optimal logistics system for proper
waste handling is a great challenge for hospitals. By direct observa-
tions and after having a detailed study, it has been deduced that
healthcare waste management systems are not properly developed
in most of the healthcare units of Pakistan. Also, healthcare profes-
sionals are not aware of the obligations regarding biomedical waste
management. Not many studies to rank supplier selection criteria
for hospital waste management in developing countries have been
done in past. Therefore, the objective of this article is the
following.
(a) Identify main criteria and their associated sub-cri-
teria from literature that are essential for supplier
selection for hospital waste management.
(b) Validate identified main criteria and their associ-
ated sub-criteria through a well-designed survey
from Pakistan’s largest city medical professionals
(doctors, nurses, lab scientist, domestic workers,
etc.).
The contribution of this article is as follows.
(a) AHP has been successfully implemented in hospi-
tal waste management in general, and particularly
in supplier selection for hospital waste manage-
ment.
(b) This study is the first of its kind in which AHP has
been applied to rank hospital waste management
supplier selection in a developing country, Paki-
stan, and the fourth most populous city in the world
and the sixth most populous metropolitan city in
the world, Karachi.
Material and methodology
The study has been conducted to apply AHP to identify, validate,
and rank main criteria and their associated sub-criteria that are
essential for hospital waste management’s supplier selection in
developing countries, specifically in Pakistan and particularly its
largest city, Karachi. Karachi is the most populous city in Pakistan,
fourth most populous city in the world and the sixth most populous
metropolitan city in the world. It has 45 hospitals, administrated
and managed by four country subdivisions, which are Federal
Government, Sindh Government, Not-for-Profit Hospitals, and
Karachi Metropolitan Corporation (KMC)/City District
Government Karachi (CDGK). The methodology presented in
Figure 1 provides a systematic approach to achieve objectives of
this study. The proposed methodology consists of two phases:
Identification and survey development, and results and analysis.
Phase 1: Identification of criteria and
sub-criteria and survey development
identification of main and sub-criteria
for hospital waste management
supplier selection
In this study, relying on recent literature, main criteria and sub-
criteria are identified. Here it is important to mention that identi-
fied criteria and their associated sub-criteria are commonly used
in literature and approved by group of doctors, nurses, lab scien-
tist, and domestic workers.
Table 1 shows the main criteria, sub-criteria, and provides a
description of sub-criteria.
388 Waste Management & Research 36(4)

Table 1.  Main and sub-criteria for hospital waste management supplier selection.

Main criteria Sub-criteria Description Reference

Waste Waste handling cost Cost incurred in provision of waste bins, trolleys, coloured bags, D’souza et al. (2016)
management (A1) PPEs, and personnel to collect/handle waste.
cost (A) Storage cost (A2) Cost of operating an area inside/near the hospitals premises
designated for waste storage before its transportation. It includes
operational cost, utility requirement, and overheads.
Transportation cost Cost incurred in waste transportation from healthcare facility to
(A3) disposal side including waste collection vehicles, bins, and freight
charges (fuel, personnel, and maintenance).
Recycling/ Recycling cost includes operational cost of plant (labour and
remanufacturing cost consumables), method of recycling, utilities, and overheads.
(A4)
Disposal/treatment Disposal cost depends on the treatment hospitals selected to Lee et al. (2004)
cost (A5) discard their waste. Different treatment ways have different cost
criteria.
Supplier Qualification (B1) Qualification is to ensure companies vehicles are equipped with Buyukozkhan and
details (B) global positioning systems, efficiently deal with the amount Gocer (2016)
of waste discarded, and conform to environmental protection
standards.
Equipment/vehicles Equipment is a criterion used to measure the container storage
(B2) capacity, elimination of redundant use of machinery, and
management information systems.
Service capability (B3) Service capability is to measure the speed up the appeal process,
provide additional services promptly, and clarify programme
alternatives and specialised skills.
Ecological Waste management (collection, segregation, and transportation) Marczak (2016)
considerations (B4) should be done keeping in mind the ecological factors.
Waste Waste collection (C1) The process of packaging and labelling are part of the collection Baati and Hachicha
handling stage. Based on demand, the disposal company collects the (2014)
procedure (C) healthcare waste in the system’s container, which is then
exchanged by the vehicle for empty containers.
Waste segregation (C2) Segregation is the separation of wastes according to the adopted Monge (2006)
classification (infectious, special, and non-risk (common, general
waste, similar to household waste)).
Waste transportation Flow of materials from the generation points towards treatment Guerrero et al.
(C3) and final disposal. (2013)
Frequency per day (C4) How often waste is collected and disposed per day.
Waste Recycling (D1) Recycling is defined as ‘the process of systematically collecting, Rezaei (2015)
treatment (D) sorting, decontaminating and returning of waste materials to
commerce as commodities for use or exchange’.
Remanufacturing/ ‘Re-manufacturing is the transformation of used units, consisting
reuse (D2) of components and parts, into units which satisfy exactly the same
quality and other standards as new units’.
Treatment before Depending upon the risk that biomedical waste carries, it should Arshad et al. (2010)
disposal (D3) be inactivated or rendered safe before final dispose in order to
minimise its harmful nature. Thermal, chemical, incineration,
filtration, or other treatment method can be used for inactivation of
waste.
Disposal methods (D4) Treatment systems for hospital wastes depending upon the Monge (2006)
characteristics of wastes.
Treatment/disposal Area/location where waste is disposed/discarded after treatment. Taghipour et al.
sites (D5) (2014)

PPE: personal protective equipment.

Hierarchy development based on
identified main and sub-criteria
AHP is considered as a general theory of management in which
paired comparison is performed and input is drawn from actual
measurements, such as price, weight, etc., or from subjective
opinion, such as satisfaction, feelings, and preference (Saaty,
1987). Because of hierarchical structures, it permits decision
makers to understand, organise, and analyse the decisive situa-
tions in a way that becomes favourable for them. Following are
Ishtiaq et al. 389
Figure 1.  Proposed methodology.
the steps of AHP (Saaty, 2008). Figure 2 shows a three-tier hier-
archy structure that we used for AHP analysis in this study. Here,
the goal is divided into four main criteria and each main criterion
is further divided into their associated sub-criteria as mentioned
in Figure 2. In this study, we have four main criteria and nineteen
sub-criteria.
Survey development for data collection
A survey was designed based on identified main criteria and their
associated sub-criteria to meet the objective of this study and to
implement AHP successfully. The survey consists of five sec-
tions which are as follows.
(a) Demographic data collection and its analysis.
(b) To rank and perform pair-wise comparison of four
main criteria, which are waste management cost,
supplier details, waste handling procedure, and
waste treatment.
(c) Five sub-criteria of waste management cost will be
rated.
(d) Four sub-criteria of supplier details will be rated.
(e) Four sub-criteria of waste handling procedure will
be rated.
(f) Five sub-criteria of waste treatment will be rated.
A sample of the survey is attached in Appendix 1 (supplemen-
tary material, available online). Participants were asked to rate
the importance of a criteria on Saatys’ scale, as mentioned in
Table 2.
We used a descriptive survey technique, which is usually
used for understanding the relevance of criteria and their asso-
ciated sub-criteria for hospitals waste management supplier
selection.
Table 2.  Saatys’ Scale for Pair-wise Comparison (Saaty,
1980).
Importance scale Importance description
1 Equal importance of ‘i’ and ‘j’
3 Weak importance of ‘i’ and ‘j’
5 Strong importance of ‘i’ and ‘j’
7 Demonstrated importance of ‘i’ and ‘j’
9 Absolute importance of ‘i’ and ‘j’
Note: 2, 4, 6, and 8 are intermediate values.
Once the survey was developed and designed, the validation
process was assessed by showing it to doctors, nurses, lab scien-
tist, and academic professional from different hospitals and med-
ical universities. A total of ten professionals, who had a minimum
of 6 years of experience in total, and a minimum of 2 years of
experience with the hospital and medical university, participated.
These professionals assessed the survey in terms of its relevance
with the objective of this study, its clarity, coherence, and average
time to fill the survey.
The survey was completed during face-to-face interviews.
We interviewed nurses, doctors, lab scientist, and domestic
workers who were working in hospitals that were under the
management of country subdivisions, including Federal
Government, Sindh Government, Not-for-Profit Hospitals, and
KMC/CDGK. At the beginning of the survey, we explained the
purpose of the survey to participants, terms and terminology
used in survey, and clarified all queries and concerns they
faced during survey filling process. Survey and data collection
was completed over a 3-month period. We followed the ethical
standards and its consideration during survey and data collec-
tion, such as confidentiality of personal information. We
selected interviewers based on their experience with the
390 Waste Management & Research 36(4)
Figure 2.  Hierarchy structure for AHP analysis.
hospital and their willingness to participate in this study. We
randomly contacted the interviewers regardless of their gender,
race, ethnicity, and biasness.
Phase 2: Results and analysis
demographic analysis of collected
data
We have distributed a total of 65 survey forms to doctors,
nurses, lab scientist, and domestic workers working in differ-
ent hospitals. Out of 65, we managed to get 35 filled surveys
from different professionals who are working in hospitals. The
survey is descriptive in nature. Distribution of gender of pro-
fessionals who participated in survey is 54.3% male and
45.7% female.
Figure 3 shows the distribution of respondent age. We clubbed
respondent ages in six age group. Our survey shows that the
majority of our survey (i.e. 31.4%) was filled by professionals
aged 20–25 years.
Figure 4 shows the number of years that the respondent had
worked in the hospital. Results show that 28.6% of respondent
were working in hospitals between 1 to 5 years.
Finally, Figure 5 shows the distribution of respondent professions.
Result shows that 40.0% of our survey respondents were doctors.
Pair-wise comparison and consistency
check
After data collection, pair-wise comparison based on survey
results was performed. Here it is important to illustrate the steps
of AHP for readers who are not familiar with AHP.
AHP
AHP is considered as a general theory of management in which
paired comparison is performed and input is drawn from actual
measurements, such as price, weight, etc., or from subjective opin-
ion, such as satisfaction feelings and preference (Saaty, 1987).
Because of hierarchical structures, it permits decision makers to
understand, organise, and analyse the decisive situations in a way
that becomes favourable for them. Following are the steps of AHP
(Saaty, 2008).
(a) Problem will be defined with proper identification
of required information.
Ishtiaq et al. 391
Figure 3.  Survey respondent age distribution.
Figure 5.  Profession of survey respondent.
(b) Hierarchy will be formulated in a way that places
goal of decision at topmost position, following the
objectives from broader perspective, then interme-
diary levels and in last, a set of alternatives.
(c) A set of pair-wise comparison matrices will be cre-
ated in which each element in an upper level will
be used to compare the elements in the level im-
mediately below with respect to it. Pairwise com-
parison will be done by the experts and it depends
on their knowledge and experience.
(d) The priorities obtained from the comparisons will
be used for weighing the priorities in the level im-
mediately below. The same procedure will be re-
peated for all elements.
(e) Overall global priority of each element in the level
below will be obtained by adding its weighed val-
ues. The process of weighing and adding will be
continued till the final priorities of the alternatives
in the bottom most levels are obtained.
(f) Using paired comparisons, decisions can be anal-
ysed from four different viewpoints: The benefits
(B), the opportunities (O) it creates, the costs (C)
that it incurs, and the risks (R) that it might have to
face. Hence, AHP facilitates users in an organised
manner so that a decision can be made without dif-
ficulty (Saaty, 2008).
In this study, we compiled survey data in a excel sheet and took
an average of all 35 respondents. It is apparent that AHP has an
advantage to check the consistency of judgment between criteria
in the phase of pair-wise comparison. As per Saaty (1980),
Figure 4.  Survey respondent duration of working in hospital.
judgment was considered to be consistence if the consistency
ration is ≤0.1.
Figure 6 shows the pair-wise comparison among main criteria
with respect to goal. We can see from the figure that inconsist-
ency is 0.04, which is ≤0.1, and as per Saaty (1980) judgment is
acceptable.
Similarly, pair-wise comparison of sub-criteria with respect to
main criteria, supplier details, the inconsistency is 0.02, with
respect to waste handling procedure is 0.09, with respect to waste
management cost is 0.01, and with respect to waste treatment is
0.04. All inconsistencies are ≤0.1 and as per Saaty (1980) judg-
ment is acceptable.
Implementation of AHP in a software
Now after the inputs of all the data in AHP software, we will go
to the main screen of the Expert Choice® software to check that
all entities and priorities have been filled and marked with green.
Figure 7 shows that all the main-criteria and their associated sub-
criteria priorities have been filled, and their local and global
weights have been calculated.
Ranking of main criteria and sub-criteria
for hospital waste management supplier
selection
Now we are ready to find out the ranking of main criteria and
sub-criteria based on the experts survey and their pair-wise
comparison. Table 3 summarises the main criteria importance
weights and their associated sub-criteria local and global
priority. It also shows the consistency ratio of each
sub-criterion.
Conclusion and future research
directions
Proper waste management can provide a healthy and safe
environment in hospitals. In developing countries there is a
lack of regulations and rules for management of effective and
efficient hospital waste. This lead to the fact that management
392 Waste Management & Research 36(4)

Figure 6.  Pair-wise comparison of main criteria with respect to goal.

Figure 7.  Overall ranking of sub-criteria with respect to goal.

and decision makers are unaware about proper and standardised
ways of management of wastes generated in hospitals.
Moreover, owing to inadequate allocation of funds from local
government, it is also one of the major factors of the absence
of rules and regulations regarding waste management. Often,
local governments in developing countries, such as Pakistan,
give less priority to sustainability. This study is an attempt to
provide guidelines to decision makers and local government
authorities to select appropriate hospital waste management
suppliers. The first objective of this study was to identify the
main criteria and their associated sub-criteria that are essential
for supplier selection for hospital waste management. We con-
sidered four main criteria and eighteen sub-criteria that are
essential for hospital waste management supplier selection.
All the criteria and their associated sub-criteria were validated
by the experts and ranked according to the experts priorities
using pair-wise comparison.
The second objective of this study was to validate identified
main criteria and their associated sub-criteria through a well-
designed survey from medical professionals (doctors, nurses, lab
scientist, domestic workers, etc.) of Pakistan’s largest city. We
conducted face-to-face interviews of hospital professionals, con-
sisting of doctors, nurses, lab scientist, and domestic workers.
Total of 35 surveys were considered in this study.
The third objective of this study was to apply AHP to rank identi-
fied main criteria and their associated sub-criteria for supplier selec-
tion for hospital waste management. Results shows that waste
management cost (45.5%) and supplier details (31.5%) are the top
Ishtiaq et al. 393

Table 3.  Summary of results.

Main criteria Importance weight Sub-criteria Local priority Consistency ratio Global priority
A 0.455 A1 0.312 0.01 0.142
A2 0.333 0.152
A3 0.107 0.049
A4 0.113 0.051
A5 0.134 0.061
B 0.315 B1 0.340 0.02 0.107
B2 0.239 0.075
B3 0.281 0.089
B4 0.140 0.044
C 0.099 C1 0.368 0.09 0.036
C2 0.301 0.030
C3 0.131 0.013
C4 0.200 0.020
D 0.131 D1 0.383 0.04 0.050
D2 0.274 0.036
D3 0.091 0.012
D4 0.149 0.019
D5 0.103 0.013

two important main criteria for hospital waste management’s sup-
plier selection. Similarly, in supplier details, qualification of supplier
(34.0%) and service capability (28.1%) are the top two sub-criteria.
In waste handling procedure, waste collection (36.8%) and waste
segregation (30.1%) are the top two sub-criteria. In waste manage-
ment cost, storage cost (33.3%) and waste handling cost (31.2%) are
the top two sub-criteria, and in waste treatment, recycling (38.3%)
and remanufacturing (27.4%) are the top two sub-criteria. Lastly, in
terms of overall ranking of sub-criteria with respect to goal, storage
cost (15.7%), waste handling cost (14.7%), and qualification of sup-
pliers (10.9%) are the top three sub-criteria.
Results from this study will provide guidelines for decision mak-
ers in selecting an appropriate waste management supplier. This
study is a stepping stone in the field of criteria of supplier selection
for hospital waste management in Pakistan and it will be beneficial
for hospitals, clinics, and miscellaneous facilities in the city.
This study has the following limitations, which can be over-
come in future research.
(a) This study is limited to only one city, Karachi, of
a developing country, Pakistan. In future, a similar
approach can be applied to other cities of Pakistan,
such as Lahore, Islamabad, Peshawar, etc.
(b) This study has applied AHP as a MCDM decision-
making approach. In future, other MCDM meth-
ods, such as ANP, DEA, fuzzy, can be applied.
(c) The survey in this study was limited to only hos-
pital professionals (doctors, nurses, lab scientists,
and domestic workers). In future, officials from lo-
cal governments and decision makers or represen-
tatives of considered hospitals can be included for
a more thorough and details analysis.
(d) In future, we can implement the results of this
study in a hospital to select the best suppliers based
on identified criteria and their associated criteria.
Despite the above-mentioned limitations, we believe that this
study is essential for developing countries, and a stepping stone
in hospital waste management generally, in developing countries
and particularly supplier selection criteria for hospital waste
management.
Acknowledgements
Authors would like to thank the sincere participation of hospitals’
professional in Karachi, Pakistan, for their time and effort in filling
out the survey forms. Also, we would like to thank the anonymous
referees for their constructive comments, which helped in enhancing
the quality of this article.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iD
Sharfuddin Ahmed Khan https://orcid.org/0000-0002-
5822-0933
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